Public health is about the relationship between the state and the individual in controlling disease and improving the population's health.
It's also a social movement, an administrative system and a medical specialism. It began with attempts to control infectious diseases in medieval times and grew to include control and improvement of the physical environment in the 1800s.
Public health measures were informed by medical theory and practice, but they were also about social and political concerns. Sometimes public health regulations were as much about controlling poor and minority populations as they were about controlling disease and improving health.
Administering public health
The state took increasing responsibility for the health of its citizens. In the UK, the first Public Health Act was passed in 1848. Reforms continued with the growth of public health bureaucracies armed with new powers.
But by the mid-1800s, doctors had begun to influence public health as much as social reformers. Leading social reformer Edwin Chadwick was a commissioner of the General Board of Health, established by the 1848 Act. He left in 1854 when the Board was dissolved. It was briefly reformed the following year, headed by John Simon as Chief Medical Officer, and when the General Board was replaced by local boards of health, Simon became the Medical Officer of Health for the City of London.
Simon oversaw the development of a new public health administration, as public health became increasingly professionalised. New specialists and experts entered the field to investigate food adulteration, occupational diseases and to take responsibility for maternity and childcare.
From the late 1840s, Medical Officers of Health were gradually introduced across England, each overseeing an increasingly large team of experts, investigators and health workers for the local community.
Initially most of these roles were fulfilled by men, but most authorities worked closely with voluntary organisations that were organised and run by women. The growing public health movement did more than collaborate with the state on public health matters—it also provided opposition to reforms such as compulsory smallpox vaccination.
But some argued that more direct action was needed to improve the health of a population.
Eugenics in science and society
The idea that a population could degenerate was linked to the idea that urban living corrupted people both physically and morally. Concerns about degeneration began during the early days of industrialisation in the 1700s, but really took off in the 1800s with mass migration from the country to the towns.
The concept of degeneration served as a vehicle for fears about rapid urbanisation, modernity and increasing democratisation. Due to a lack of understanding of how infectious diseases were spread, some people wrongly believed that certain diseases such as tuberculosis were hereditary and could be passed on to weaken future generations.
In 1869 Charles Darwin published his theory of selective evolution, which was appropriated by social Darwinists to support degeneration. Darwin's cousin Francis Galton claimed that because more of the 'unfit' survived in modern society, natural selection was hindered and society was not evolving as it should.
Galton invented the science of eugenics based on his research. He measured and collected anthropomorphic data on a host of human attributes including longevity, muscle strength and 'success in life'.
By pulling together concerns about population growth with fears of urban degeneration, Galton put the idea of heredity in the public health sphere. He argued that the British race risked degeneration because of the differential birth rates between the 'feckless poor' and the 'responsible middle class'.
The fear was that the British could not rule their empire effectively if the health and fitness of its people were in question. Maintaining good health and education was no longer just about self-improvement—it was the responsibility of every citizen to be the best human being they could for the sake of the nation.
The impact of eugenics on public health
Eugenics was both a social movement and a science, but in Britain the influence of eugenics remained largely as the former. The extent of its impact on politics was the 1904 Report of the Inter-Departmental Committee on Physical Deterioration. This report favoured social and environmental measures to promote good health, such as maternity and child welfare, but did not enforce birth control. However, it also played a role in justifying continued colonial rule around the world.
On one hand, public health campaigns were about improving the environment and health of the population—but on the other, they sought to improve the health of the nation by removing undesirable elements such as 'degenerate' groups and inherited weakness.
Much of the voluntary birth control movement was motivated by concerns to reduce the population among the poor. Their aim was to persuade working class women to have fewer children as a way out of poverty, but they also believed that by controlling human reproduction, humanity could take control of its own future.
But in other countries, especially in Nazi Germany, it gained a much stronger political stronghold. Sweden, for example, introduced compulsory measures for birth control.
The influence of eugenics faded in the aftermath of the Second World War (1939–45), and in Britain the further expansion of government involvement in health culminated with the emergence of the welfare state. This was characterised by the introduction of financial and medical assistance from the cradle to the grave.
The role of the state in public health
The late 1900s and early 2000s saw public health measures shift once again, to addressing epidemics of chronic disease such as smoking-related lung cancer, diabetes and heart conditions, especially in wealthy nations.
As with infectious diseases, prevention remains the key strategy for public health campaigns. But diseases of lifestyle require a more complex approach, often involving persuasion and education rather than medical intervention or aggressive legislation.
Public health efforts to encourage people to give up smoking, for example, used a mix of legislation and raising public awareness through education and advertising.
As long as the state intervenes in the health of nation, there remains a difficult line between the right of the individual to smoke or not be vaccinated, for example, and the desire to protect the whole community from passive smoking or infectious disease.
International public health
With rapid and increasing globalisation, state-wide public health programmes could only do so much. European scientists took advantage of access to colonial locations in India, Hong Kong and Africa to carry out trials and field research.
Researchers worked in the global arena to create vaccines for the plague and cholera and to identify the cause of malaria. By the 1920s, public health took a more international turn.
As vaccines were developed for diseases such as smallpox and typhoid, mass immunisation programmes were instituted. The World Health Organisation (WHO) ran a campaign to eradicate smallpox through mass vaccination, which it successfully achieved in 1979.
A similar campaign to eradicate polio is very close to achieving its goal. Other campaigns, such as one to eliminate malaria through DDT habitat clearance, proved unsuccessful. But the WHO continues to play a role in identifying global health risks and setting agendas for national and international public health policies.
Suggestions for further research
- V Berridge, Public Health: A Very Short Introduction (Very Short Introductions) (Oxford: OUP, 2016)
- R M Packard, A History of Global Health: Interventions into the Lives of Other Peoples, (Baltimore: Johns Hopkins University Press, 2016)
- A Saini, Superior: The Return of Race Science, (Boston: Beacon Press, 2019)
- M Stopes, Radiant Motherhood: A Book for Those Who are Creating the Future, (New York: Putnam, 1920)